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Oncology Nursing Forum
The Effects of Foot Reflexology on Anxiety and
Pain in Patients With Breast and Lung Cancer
January/February 2000, Volume 27, Number 1
Nancy L.N. Stephenson, PhD, RN, CS, Sally P. Weinrich, RN, PhD,
FAAN, and Abbas S. Tavakoli, DrPH
Abstract
Key Points
Reflexology
Methods
Results
Discussion
References
Abstract
Purpose/Objectives: To test the effects of foot reflexology on
anxiety and pain in patients with breast and lung cancer.
Design: Quasi-experimental, pre/post, crossover.
Setting: A medical/oncology unit in a 314-bed hospital in the
southeastern United States.
Sample: Twenty-three inpatients with breast or lung cancer. The
majority of the sample were female, Caucasian, and 65 years or
older; had 12 or fewer years of education and an annual income of
$20,000 or more; and were receiving regularly scheduled opioids
and adjuvant medications on the control and intervention day.
Methods: Procedures included an intervention condition (foot
reflexology to both feet for 30 minutes total by a certified
reflexologist) and a control condition for each patient (with at least a
two-day break). No changes were made in patients' regular
schedule or medications.
Main Research Variables: Anxiety and pain.
Findings: Following the foot reflexology intervention, patients with
breast and lung cancer experienced a significant decrease in
anxiety. One of three pain measures showed that patients with
breast cancer experienced a significant decrease in pain.
Conclusions: The significant decrease in anxiety observed in this
sample of patients with breast and lung cancer following foot
reflexology suggests that this may be a self-care approach to
decrease anxiety in this patient population.
Implications for Nursing Practice: Professionals and lay people
can be taught reflexology. Foot reflexology is an avenue for human
touch, can be performed anywhere, requires no special equipment,
is noninvasive, and does not interfere with patients' privacy.
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Key Points
1. Foot reflexology is a form of foot massage that targets
points on the foot believed to correspond to parts of the
body.
2. With an increased interest in complementary therapies, foot
reflexology may appeal to oncology nurses because of the
potential relaxation effects.
3. Study findings indicate that foot reflexology has a possible
positive effect on anxiety reduction. Effects on pain
reduction are less clear.
4. Nurses interested in using foot reflexology should undergo
training and certification.
Many patients living with cancer experience anxiety, and 75% of
patients with advanced cancer experience pain (U.S. Department of
Health and Human Services, 1994). Patients must manage their
anxiety and pain as chronic problems.
Patients with cancer often try alternative therapies (e.g., massage,
reflexology, therapeutic touch, herbs, special diets) (Dossey,
Keegan, Guzzetta, & Kolkmeier, 1995; Montbriand, 1994). However,
patients often make these choices based on limited information
about the efficacy of the therapies (Montbriand, 1995). Healthcare
providers must conduct more research about these therapies if they
are to help patients make wise choices about them (Montbriand,
1993).
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Reflexology
Reflexology is a form of foot massage designed to harmonize bodily
functions and thus have a healing and relaxing effect (Tappan,
1978). Reflexology is based on the premise that "there are reflex
areas in the feet and hands that correspond to all of the glands,
organs, and parts of the body" (Byers, 1983, p. 11). Reflexology has
been used since ancient times to promote relaxation (Booth, 1994;
Byers; Dobbs, 1985). In recent years, it has been used as an
alternative or complementary therapy to relieve stress and tension,
improve the blood supply, and promote homeostasis (Dossey et al.,
1995; Micozzi, 1996). Explanations for its effects are based on
several theories. For example, the energy theory proposes that
organs communicate via an electromagnetic field and reflexology
assists energy to recirculate through blocked pathways. The lactic
acid theory states that lactic acid is deposited as microcrystals in the
feet and reflexology crushes the crystals and allows for the free flow
of energy. The theory of proprioceptive nervous receptors states that
a connection exists between the areas of the feet and the body
organs and that reflexing the feet affects the organs. Foot
reflexology produces its relaxing effect by relieving tension and
stress related to physical problems. This relaxation affects the
autonomic response, which, in turn, affects the endocrine, immune,
and neuropeptide systems (Dossey et al.). Finally, the psychological
explanation states that reflexology is simply a method of showing
care and concern for patients (Dobbs). Reflexology's relaxing effect
supported this study.
No research has examined reflexology as a treatment for patients
with cancer, although studies have tested the effects of other
nonpharmacologic interventions (e.g., massage) on patients' anxiety
and pain (Barbour, McGuire, & Kirchhoff, 1986; Crowther, 1991;
Ferrell, Cohen, Rhiner, & Rozek, 1991; Ferrell-Torry & Glick, 1993;
Meek, 1993; Weinrich & Weinrich, 1990; Wilkie, Lovejoy, Dodd, &
Tesler, 1988). Patients with cancer cited massage as a method of
nonpharmacologic pain control they used (Barbour et al.). While
observing patients' pain-control behaviors, researchers noted the
use of more pain-control behaviors than patients reported (Wilkie et
al.), which supports inclusion of participant observation in research
designs examining patients with cancer who are experiencing pain.
A pilot study found that male patients with cancer experienced a
significant decrease in pain after a 10-minute massage (Weinrich &
Weinrich). Although pain was not significantly decreased one to two
hours following massage, massage was advocated as a short-term
nursing intervention. Ferrell-Torry and Glick found similar results
after patients with cancer received a 30-minute massage. These
nine men demonstrated a decrease in physiologic indicators and
improved self-reports of their perception of pain and anxiety. Meek
confirmed positive results after male and female patients enrolled in
hospice received a three-minute back massage. The patients'
decrease in heart rate and diastolic blood pressure and increase in
skin temperature were evidence of their increased relaxation.
Ferrell et al. (1991) reported that patients with cancer experienced
decreased pain specifically after foot massage, but no other
research about reflexology and patients with cancer has been
reported. However, reflexology treatments during an eight-week
period in a randomized controlled study decreased premenstrual
signs and symptoms (including anxiety) significantly more in an
intervention group than in the placebo group (n = 35) (Oleson &
Flocco, 1993). Omura (1994) used a procedure to map organ
representation on the hands and feet of 10 subjects. Omura did not
report statistical significance but claimed physiologic results based
on an anatomic design. Reflexology has been used as an alternative
or complementary therapy to relieve stress and tension, improve the
blood supply, and promote homeostasis (Dossey et al., 1995;
Micozzi, 1996). This article reports a study of the effects of
reflexology on anxiety and pain in patients with cancer.
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Methods
This study was a quasi-experimental, pre/post, crossover trial, with
patients serving as their own control (Daly, Bourke, & McGilvray,
1991). This design is appropriate when a treatment such as
reflexology produces an immediate effect that may disappear after
the treatment is removed. The patients were randomized to two
groups: Group A (receiving reflexology on the first contact) and
Group B (receiving reflexology on the second contact). The
researcher used a coin toss to determine which patients were
assigned to the control group first and which patients were assigned
to the intervention group first. The researcher then alternated
assignment of control and intervention for each of the patients,
ensuring that every other patient was assigned to Group A or Group
B. Anxiety and pain were measured prior to the intervention, at the
beginning of the control time (a 30-minute time period during a day
without the intervention), following the intervention, and at the end of
the control time.
Setting and Sample
Patients were on an 18-bed medical/oncology unit in a large regional
hospital in the southeastern United States. All patients with lung or
breast cancer were included in the study during a 20-week period if
they were 21 years or older, spoke English, and gave informed
consent. Only patients with breast and lung cancer were chosen to
limit the types of chronic cancer-related pain (somatic or visceral).
Payne (1990) and Portenoy (1990) recommended limiting the types
of pain. Because different cancers have different pain
characteristics, limiting the types of pain makes the population more
homogenous. A nurse researcher asked the patients with breast and
lung cancer who met the criteria (determined through chart review)
to complete a visual analogue scale (VAS) for anxiety (Herman,
1990). If patients reported any anxiety on the VAS, they were asked
to participate in the study. Patients with cancer who reported no
anxiety on the VAS were excluded. Patients who had surgery within
the past six weeks, open skin wounds on their feet, a foot tumor or
foot metastasis, or radiation treatment to the feet also were excluded
to separate patients experiencing chronic pain from those
experiencing acute pain (City of Hope National Medical Center and
Beckman Research Institute, 1993). Patients who received radiation
to the site of pain were excluded. Patients with dementia or
peripheral neuropathy also were excluded to ensure their responses
were accurate (McDonald & Bruera, 1990). In addition, patients who
had recent surgery were excluded to differentiate chronic cancerrelated pain from acute surgical pain (Coyle & Foley, 1987).
The oncologists required a medical consultation before the
researcher was allowed to seek participation in the study from
patients exhibiting any possible symptoms of deep vein thrombosis.
Reflexology is not contraindicated for patients with deep vein
thrombosis, but the required medical consultation was physician
preference. As in other studies (Booth, 1994; Byers, 1983), patients
with lower limb circulatory problems (e.g., phlebitis, gallstones,
kidney stones) did not receive foot reflexology to the areas of the
foot associated with the diseased areas of the body but received
foot reflexology to other areas of the foot. Avoiding reflexology to the
affected areas of the foot that are associated with other problem
areas of the body is a safety precaution to prevent, for example,
stones or possible emboli from moving and causing complications.
Most of the patients on the medical/oncology unit experienced
chronic cancer-related pain for which pain medications were
ordered. Twenty-four patients agreed to participate in the study;
however, one patient died before the reflexology intervention,
leaving a final sample of 23. Even though all of the patients
experienced pain at some time during their hospitalization, they did
not always experience it during the time of measurement for the
study.
Intervention
The International Institute of Reflexology, which uses the Original
Ingham Method, trained and certified the researcher as a
reflexologist. Before patients were enrolled in the study, reflexology
was described explicitly to them through a written protocol and a
form that illustrated the areas that would be reflexed (i.e., areas on
the foot related to a body part or organ that are stimulated by
pressure of the reflexologist's thumb or forefinger).
Foot reflexology was chosen because most of the patients were
receiving IV fluids through the hands or arms, making hand
reflexology less appropriate. Of the 30-minute reflexology session,
15 minutes were spent reflexing the areas of the feet corresponding
to areas of patients' self-reported pain and organs or body parts
where cancer sites were located (to promote homeostasis) (Byers,
1983; D. Byers, personal communication, November 1, 1996). If
patients reported no pain, the reflex areas on the feet associated
with the organs or body parts where the cancer was located were
reflexed. The specific areas reflexed for breast cancer and lung
cancer (i.e., the balls of the feet and on top of the feet over the balls)
are identical. Byers defined helper areas as areas that, when
reflexed, may have a direct effect on the afflicted areas and are
used as reinforcements. These areas were reflexed to aid the
specific area of the pain or cancer sites. Helper areas included the
pituitary, thyroid, and adrenal glands to boost the immune response
to stress (D. Byers, personal communication, November 1, 1996). If
swelling was a problem, areas of the feet corresponding to the
lymphatics were reflexed. The area corresponding to the solar
plexus was reflexed on all patients as part of the relaxing
techniques. Relaxing techniques, administered at the beginning and
end of the session, comprised 10 minutes of the 30-minute
reflexology session. Relaxing techniques consisted of a back-andforth movement of the reflexologist's palms on the outer edges of the
patients' metatarsals and an ankle-loosening technique in which the
reflexologist's palms were used to reflex the outer edges of the
patients' ankles. Five minutes were devoted to reflexing the entire
area of the feet to ensure that all areas of the body were covered.
Thirty-minute foot reflexology sessions are recommended (Byers,
1983; Oleson & Flocco, 1993; Rick, 1986; Tappan, 1978) and were
administered using a crossover design during one of two
consecutive researcher visits with each patient, between 7 am and 7
pm. Half of the patients received reflexology first and then served as
their own control. The other half of the patients served as their own
control first and then received reflexology. Hospital-brand lotion was
applied to the feet at the end of the session (lotion was withheld
during the reflexology to prevent the reflexologist from slipping over
an area). The reflexologist responded to the patients' comments or
questions during the session.
No intervention was used during the 30-minute control time. The
researcher was not present during this time. At least 48 hours
elapsed between the reflexology intervention and the control time.
The mean time between the intervention and control was 2.4 days,
with a maximum interval of 7 days. Patients continued their regular
routine of rest and activity during that time period.
Instruments
Two instruments were used to measure anxiety and pain. The VAS,
the simpler of the two instruments, was used to measure anxiety
and administered first so that the procedure for completing a VAS
could be explained. The VAS for anxiety is a 10-cm line with verbal
anchors at each end stating "not anxious at all" to "the most anxious
I have ever been" (Cline, Herman, Shaw, & Morton, 1992; McGuire,
1988). The VAS score ranged from 0-100. The instrument has been
standardized and is reliable (Cline et al.).
The Short-Form McGill Pain Questionnaire (SF-MPQ) (Melzack,
1987) was used to measure pain. It contains descriptor words
representing the sensory dimension of the pain experience
(throbbing, shooting, stabbing, sharp, cramping, gnawing, hotburning, aching, heavy, tender, and splitting). Four descriptors
(tiring-exhausting, sickening, fearful, and punishing-cruel) depict the
affective dimension. The words are ranked according to intensity
from 0-3 (none, mild, moderate, severe) (Melzack). The Present
Pain Intensity (PPI) component of the SF-MPQ and a VAS measure
the pain intensity. The PPI scores range from 0-5 and are
accompanied by descriptor words (no pain, mild, discomforting,
distressing, horrible, and excruciating).
The SF-MPQ takes only two to five minutes to administer and
correlates highly with the sensory, affective, and total indices of the
longer McGill Pain Questionnaire. It is sensitive to therapies such as
analgesic drugs, epidural blocks, and transcutaneous electrical
nerve stimulation (Melzack, 1987). Validity and reliability of the SFMPQ have been established with patients with chronic cancer pain
(Dudgeon, Raubertas, & Rosenthal, 1993). Correlations between the
long and short forms ranged from r = 0.81-0.97 for the descriptive
words.
Demographic data collected included age, gender, race, education,
and income. Other pertinent information included diagnoses
(specific type of cancer, metastasis sites, and diagnoses other than
cancer) and, based on a previous study (Stephenson, 1990),
medications (pain and other medications) taken within the last 24
hours.
Data Analysis
Data were analyzed using the Statistical Analysis System and
provided descriptive statistics, correlations, and univariate analysis.
The Wilcoxon and Signed-Rank tests were used for analyses
because of the highly skewed distribution of data.
Group A and Group B each were pretested and post-tested at two
separate times. Medications were treated as categorical variables.
Demographic data were collapsed into two categories for each
variable to enhance the clarity of the data.
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Results
Of the total sample of 23 patients, 13 (56.5%) had breast cancer and
10 (43.5%) had lung cancer (see Table 1). Of the 13 patients with
breast cancer, 10 had metastases. Of the 10 patients with lung
cancer, 5 had metastases.
Medications given to the sample on control and intervention days
were not significantly different. On the control and intervention days,
14 patients (61%) received opioids. On the control day, six patients
(26%) received nonopioid analgesics, and, on the intervention day,
seven patients (30%) received nonopioid analgesics.
Anxiety
Anxiety scores, used to measure the effects of foot reflexology on
anxiety, were significantly lower after foot reflexology in both groups
of patients and between the two groups. Table 2 indicates post-test
scores minus pretest scores with the reflexology intervention and the
differences between anxiety scores of the control group and
following reflexology treatments.
Pain
The 13 patients with breast cancer (11 reporting pain) experienced a
significant decrease in pain following foot reflexology as measured
by the descriptive words of the SF-MPQ (see Table 3). Because
only two patients with lung cancer reported pain, results from this
group of subjects could not be calculated. The differences in pain
between the groups as measured by the PPI and VAS were not
significant.
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Discussion
Patients with breast and lung cancer experienced significantly
decreased anxiety following reflexology. Patients with lung cancer
experienced the greatest decrease in anxiety. Because the majority
of these patients were male, gender was a confounder with cancer
type.
In addition, patients with breast cancer experienced significantly
decreased pain, as measured by the descriptive words of the SFMPQ, following reflexology. Additional study is required to determine
the effects of foot reflexology on pain as measured by the intensity
sections of the SF-MPQ, the VAS, and the PPI. The fact that the
mean pain score on the VAS was only 20.13 for the sample as a
whole before reflexology and most patients with lung cancer
reported no pain at the time of measurement may explain, in part,
the nonsignificant decrease in pain in either group. Other patients
were taking medications to manage their pain.
The findings of this study are consistent with the literature regarding
reflexology (Oleson & Flocco, 1993; Omura, 1994). Reflexology can
be used to decrease anxiety and pain in patients with cancer.
Despite the fact that the patients in this study were taking drugs to
manage pain, 61% reported pain at some time during the study.
Reflexology also can be an avenue for increasing human touch,
which is a basic human need. Reflexology can be performed
anywhere, requires no special equipment, is noninvasive, and does
not interfere with patients' privacy. Some patients in this study were
concerned that their feet might have an odor. Washing patients' feet
first and applying cornstarch if the feet are moist can remedy this
concern.
Future research studies are needed to compare reflexology with
other complementary/alternative therapies (e.g., massage, healing
touch, relaxation response). Repetitive sessions of reflexology might
be studied for a cumulative effect. Research on cost-effectiveness
and gender and aging differences associated with reflexology would
enhance the efficacy of practitioners' incorporation of reflexology into
their practice. Research to ensure that the best nonpharmacologic
methods are matched with different types of pain will contribute to
the expanding knowledge of pain.
Limitations of this study were the small sample size (considering that
only two of the patients with lung cancer reported pain during the
measurement) and the unusually high representation of males with
lung cancer. The crossover design allowed the 23 patients to be
their own control, which lessened the problem of a small sample
size. Because only 11 patients with breast cancer measured pain
that was reportable, future studies would benefit from a pain score
minimum as part of the inclusion criteria. Replication with a larger
sample of a single cancer type is necessary to limit the type of pain.
Studies testing nonpharmacologic interventions for anxiety and pain
continue to be a challenge but will provide vital information for
healthcare providers to manage symptoms of patients with cancer.
Nurses who wish to incorporate reflexology in their practice can
study it in the book Better Health With Foot Reflexology (Byers,
1983). Certification in reflexology through the International Institute
of Reflexology involves 100 hours of study (books, study guides,
videos, and seminars), 100 hours of documented practice of
reflexology sessions, and a written and practical examination about
the Ingham Method of Reflexology. Certification is the best way to
ensure proper performance of the technique and can be obtained in
a minimum of nine months. Practitioners can obtain more
information about reflexology by contacting International Institute of
Reflexology, 5650 1st Avenue North, St. Petersburg, FL 33710-7912
(727-343-4811; [email protected], e-mail;
http://www.reflexology-usa.net/, Web site).
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Nancy L.N. Stephenson, PhD, RN, CS, is an assistant professor in
the School of Nursing at East Carolina University in Greenville, NC.
Sally P. Weinrich, RN, PhD, FAAN, is a professor in the College of
Nursing at the University of Louisville in Kentucky. Abbas S.
Tavakoli, DrPH, is a statistician in the College of Nursing's Office of
Research at the University of South Carolina in Columbia.
(Submitted April 1999. Accepted for publication August 2, 1999.)
Author Contact: [email protected] with copy to editor at
[email protected]
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